HESI RN
HESI 799 RN Exit Exam
1. When a client with a history of atrial fibrillation is admitted with a new onset of confusion, which diagnostic test should the nurse anticipate preparing the client for first?
- A. Electrocardiogram (ECG)
- B. Chest X-ray
- C. Arterial blood gases (ABGs)
- D. Echocardiogram
Correct answer: A
Rationale: The correct answer is an Electrocardiogram (ECG). When a client with a history of atrial fibrillation presents with new-onset confusion, an ECG is crucial to assess for cardiac ischemia, which could be a potential cause of the confusion. A chest X-ray (Choice B) is not typically the first-line diagnostic test for evaluating confusion in a client with atrial fibrillation. Arterial blood gases (ABGs) (Choice C) are more useful in assessing oxygenation and acid-base balance rather than the cause of confusion in this scenario. While an echocardiogram (Choice D) provides valuable information about cardiac structure and function, it is usually not the initial diagnostic test needed in the evaluation of acute confusion in a client with atrial fibrillation.
2. A client's subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next?
- A. Collect a clean-catch specimen
- B. Administer prescribed antibiotics
- C. Perform a bladder scan
- D. Increase the client's fluid intake
Correct answer: A
Rationale: The correct action for the nurse to implement next is to collect a clean-catch specimen. This is essential to diagnose the cause of the client's symptoms accurately before initiating any treatment. Administering antibiotics (Choice B) without confirming the diagnosis through a specimen collection can be inappropriate and potentially harmful. Performing a bladder scan (Choice C) may not provide the necessary information to identify the specific cause of the symptoms. Increasing the client's fluid intake (Choice D) is a general recommendation and may not address the underlying issue causing the symptoms.
3. Which intervention by the community health nurse is an example of a secondary level of prevention?
- A. providing a needle exchange program at a community mental health clinic
- B. developing an educational program for clients with diabetes mellitus
- C. administering influenza vaccines to residents of a nursing home
- D. initiating contact notifications for sexual partners of an HIV client
Correct answer: C
Rationale: Administering influenza vaccines to residents of a nursing home is an example of secondary prevention. Secondary prevention aims to detect and treat a disease or condition in its early stages to prevent complications. In this case, administering influenza vaccines helps prevent the spread of the flu among vulnerable individuals. Choices A, B, and D are not examples of secondary prevention. Providing a needle exchange program (Choice A) is a harm reduction strategy (tertiary prevention). Developing an educational program for clients with diabetes mellitus (Choice B) focuses on health promotion and primary prevention. Initiating contact notifications for sexual partners of an HIV client (Choice D) is a measure to prevent further transmission of the disease but is more aligned with tertiary prevention.
4. A client has been diagnosed with hyperthyroidism. Which of these nursing diagnoses should receive the highest priority?
- A. Risk for injury related to exophthalmos
- B. Impaired social interaction related to emotional lability
- C. Imbalanced nutrition: Less than body requirements related to hypermetabolism
- D. Activity intolerance related to fatigue
Correct answer: D
Rationale: The correct answer is 'D: Activity intolerance related to fatigue.' This nursing diagnosis should receive the highest priority for a client with hyperthyroidism. Hyperthyroidism often leads to symptoms such as fatigue, weakness, and muscle discomfort, which can significantly impact the client's ability to perform daily activities. Addressing activity intolerance is crucial to prevent exacerbation of symptoms and promote the client's overall well-being. Choices A, B, and C are important nursing diagnoses as well, but in the context of hyperthyroidism, addressing activity intolerance takes precedence over the risk for injury related to exophthalmos, impaired social interaction related to emotional lability, and imbalanced nutrition due to hypermetabolism.
5. The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA)
- A. Purchase a gun for protection.
- B. Establish a code with family and friends to signal violence.
- C. Take a self-defense course focused on protection.
- D. Prepare a bag with extra clothes for self and children.
Correct answer: B
Rationale: Establishing a code with family and friends is crucial in situations of intimate partner violence as it allows discreet communication for help without alerting the abuser. Having a pre-prepared bag with essentials like extra clothes is important to facilitate a quick exit if necessary. Purchasing a gun is not a recommended safety strategy as it can escalate violence and pose more danger. While taking a self-defense course focused on protection is beneficial, it is essential to avoid courses that emphasize retaliation, as they can increase the risk and escalate violence.